Clinical Procedures & Protocols Flashcards

A parish nurse is performing a wound assessment on a home-bound client. Which characteristic of wound exudate indicates possible infection?

Answer: Purulent (thick, yellow-green, malodorous) drainage

Purulent drainage that is thick, yellow-green, or malodorous indicates the presence of infection and requires prompt physician referral.

When teaching a congregation member newly diagnosed with type 2 diabetes about the 'sick day rules,' the parish nurse should instruct them to:

Answer: Continue medications, monitor blood glucose more frequently, and call the provider if glucose is consistently above 240 mg/dL

During illness, glucose levels often rise; diabetic clients should continue medications, increase monitoring, stay hydrated, and contact their provider if glucose exceeds 240 mg/dL or ketones are present.

A parish nurse is using the Body Mass Index (BMI) chart to assess a congregation member. A BMI of 32 kg/m² classifies the individual as:

Answer: Class I Obesity

According to CDC/NIH classifications, a BMI of 30.0–34.9 kg/m² is defined as Class I Obesity, associated with increased health risks.

A parish nurse is counseling a 65-year-old congregation member about recommended immunizations. Which vaccine is recommended annually for this age group?

Answer: Influenza vaccine

The CDC recommends annual influenza vaccination for all adults, especially those aged 65 and older who are at higher risk for complications from flu.

During a blood pressure screening, a parish nurse obtains a reading of 158/96 mmHg in a first-time client. The appropriate response is to:

Answer: Recheck in the other arm, document the finding, and refer the client to their primary care provider

A single elevated reading should be rechecked in the other arm, documented, and the client referred to a primary care provider for follow-up diagnosis and management.

A parish nurse is teaching a congregation member about proper use of a home pulse oximeter. Which factor can produce a falsely low SpO2 reading?

Answer: Wearing dark nail polish on the monitored finger

Dark nail polish absorbs light in the same wavelengths used by pulse oximeters, interfering with accurate SpO2 readings and causing falsely low values.

A parish nurse finds an elderly homebound client who is confused, has dry mucous membranes, and has not urinated in over 8 hours. The nurse suspects:

Answer: Dehydration requiring prompt fluid replacement and physician contact

Confusion, dry mucous membranes, and decreased urine output are classic signs of dehydration in older adults, which can quickly become life-threatening and requires prompt intervention.